Patients with Alzheimer’s and other forms of dementia are increasingly being referred for end-of-life care with hospice. The segment of the population over 80 is the fastest growing and therefore the one most susceptible to the terminal phase of these dementias.
Alzheimer’s can typically run a course from eight to 20 years. Other dementias can also be long and cruel durations. Some common causes of dementia can be strokes, Parkinson’s disease, Huntington's disease, MS, AIDS, and brain infections.
Dementia affects the ability not only to remember on a short term and/or long term basis, but also the ability to care for oneself. As dementia progresses, the person becomes unable to perform activities of daily living (ADLs) such as eating, dressing, bathing, grooming, toileting, and even walking without assistance.
If there are co-morbid diseases such as heart disease, diabetes, liver, lung or kidney disease, they can be adversely affected by the dementia. Simple tasks as remembering to take medications can become a problem and the symptoms of these diseases will no longer be controlled.
Infection Control
Infections caused by skin breakdown from incontinence can become major issues. The use of Foley catheters can be an avenue for infection and should be avoided in dementia patients. Incontinence of stool can lead to urinary tract infections (UTI) with or without the use of catheters.
UTIs are common in dementia patients and often difficult to diagnose early on as the patient may not experience any pain or discomfort. Fever can be missed because the normal body temperature in dementia patients is often lower than the norm of 98.6 and so a temperature of 98.4 may be considered normal when indeed it is a low grade fever for that patient.
Choking and aspirating food into the lungs is another problem that leads to frequent infection in dementia patients. Dementia affects the brain’s ability to remember how to chew and swallow presenting challenges for caregivers who must be patient feeders. Slow feeding, thickened liquids, and chopping solid foods is a must. Care should be taken to ensure the foods and liquids remain palatable. The better foods taste, the easier feeding will be.
Certification of Terminal Illness
For a patient to qualify for hospice care, the physician has to certify that if their illness runs its normal course, the patient has six months or less to live. For hospice care to be most effective, the earlier it is elected, the better. In dementia patients, this is not always as clear cut a process as it can be for other disease processes.
Medicare has set guidelines to help determine eligibility in Alzheimer's and dementia patients. Hospice agencies can assist families and physicians in making this determination. If the patient does not qualify, they can make appropriate referrals. As palliative care becomes mandated over the next couple of years, this may be an excellent alternative choice until the patient meets hospice guidelines.
Qualifications for Hospice Care
The qualifications include being dependent in most ADLs, incontinent of bowel and bladder, unable to converse effectively, and exhibiting outward signs of decreasing nutritional status such as weight loss in the last six months. Clinical manifestations support the terminal status such as a UTI, aspiration pneumonia, stage III or IV bedsores, a severe health issue, or a Serum albumin of < 2.5m/dl.
The focus of hospice care for dementia and Alzheimer’s patients is palliative and involves controlling and preventing behavioral issues as well as infections and complications such as UTIs, aspiration, and bedsores. The emotional support may be lost on the dementia patient, but supporting caregivers and family members through the journey is a valuable aspect for them.
Resources:
Which late-stage Alzheimer's Patients Should be Referred for Hospice?
Kathy Quan - Kathy Quan RN BSN has been a home health/hospice nurse for over 30 years. She has authored five books and writes for several online ...
